A 23 year old male with fever

 A 23 year old man from Hyderabad Car mechanic by occupation came to the OPD with

C/o Fever for 2 days prior to admission

History of presenting illness

Patient was apparently asymptomatic 5 days back then he developed fever on Friday night that is on 15th of July 2022 which was associated with chills and fatigue.Next day morning he took an antipyretic(dolo 650mg) which was not helpful in subsiding the fever. 

A day later he visited an RMP doctor as the fever did not subside and was treated symptomatically. He was asked to go to a better hospital to get diagnosed and treated as the fever didn't seem to come down. Fever lasted for only two days according to the patient. 

No spikes of fever since admission

H/o fatigue associated with fever

No h/o headache, muscle pains, joint pains,rash.

No h/o cough, abdominal pain, dysuria, diarrhoea, nausea, vomitings

Habitat- Patient informs that his habitat contains a lot of mosquitoes. 

Past history

No similar complaints inthe past

N/k/c/o Diabetes, Hypertension, Asthma, Epilepsy and Tuberculosis. 

Personal history

Appetite- Normal

Diet- Mixed

Sleep-Adequate

Bowel and bladder movements- Regular

Addictions- None

Family history -No similar complaints in the family

Allergy history - No known allergies

General Physical Examination

Patient is conscious, coherent and cooperative

Well oriented to time, place and person. 

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Generalized lymphadenopathy, Edema. 

Vitals

Temperature- 98.6° F

Pulse - 66 bpm

Respiratory rate - 16 cpm

BP - 100/70 mmHg

Systemic examination

Abdomen - Soft, Non tender 

CVS - S1, S2 heard

Respiratory system - BAE present

CNS - No focal neurological deficits

Investigations

Hemogram shows decrease in Platelet count  and highly increased monocytes 


Dengue NS1 antigen appears positive


Liver function tests show elevated SGOT and SGPT

Renal function tests show decreased creatinine, uric acid and slightly elevated Sodium levels

Complete Urine examination shows no abnormal findings

Provisional diagnosis
Viral fever with positive NS1 antigen and with no hemorrhages or petichae 

Treatment

IVF 10 NS/10 RL
Tab. Doxy 100mg po/BD
Tab. Dolo 650mg po/BD
Tab. Pantop 40mg po/BD
Temperature monitoring
Plenty of fluids

Increase in platelet count has been noticed on keeping the patient on observation. 



Comments

Post a Comment

Popular posts from this blog

A 28 year old male with Gross Ascites

Image
 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. A 28 year came to OPD with C/o Abdominal distention since 10 days        Abdominal discomfort since 10 days History of Presenting illness  Patient was apparently asymptomatic 10 days ago then he developed Abdominal discomfort and distention of abdomen for which he visited a primary health care centre near his residence where he was adviced to get an Xray of Abdomen for which he visited our Institution. Abdominal distention was insidious in onset and gradually progressed to current size  Patient
Read more

60 year old male with trunkal obesity with URTI, HFMEF, DM, HTN

Image
A 60 year old male came to casuality with C/o Cough, cold since 3 days         Chest pain since 1 day         Fever since 1 day HOPI Patient was apparently asymptomatic 3 days ago then he developed cough with sputum, scanty in quantity, green in color associated with cold and nasal blockage H/o Fever, low grade, continuous non aggravating and no relieving factors No h/o rash, retroorbital pain, arthralgia C/o chest pain, diffuse, squeezing type associated and aggrevating with cough, non relieving  No h/o abdominal pain, vomiting, diarrhea  No h/o seizures, tremors Past history : K/c/o DM, HTN since 10 years and on unkown medication  N/k/c/o Asthma, CAD, CVA, Thyroid disorders, Epilepsy General examination  Pt is C/C/C No Pallor, Icterus, Cyanosis, Lymphadenopathy, Edema Vitals Temperature - 100.8°F PR - 104 bpm BP - 110/70 mmHg RR - 22 cpm SpO2 - 93 @ 4L O2 GRBS - 301 mg% Systemic Examination CVS - S1,S2 heard RS - BAE present  CNS - NFND P/A - Soft, Non tender Investigations on admiss
Read more

39 year old male patient with Altered sensorium and Paraplegia

Image
A 39 year old male patient resident of Nalgonda, electrician by occupation was presented to the casualty on 9th of November,2021 As informed by his attenders C/o decreased responsiveness, loss of appetite and decreased speech since 2 days before admission and completely couldn't talk on the day of admission.  History of presenting illness   Patient was apparently asymptomatic 8months ago then he developed pain abdomen and intermittent low back pain and dribbling of urine so he visited a physician and was told to have renal stones and meatal stenosis for which he underwent urethral dilatation in July, 2021.  He was incidentally detected to have serum creatinine 5g/dL while visiting a hospital in Nalgonda. His urine output was good and he had no pedal edema or sob. He was told to have renal failure and was on medication since then. He had h/o weight loss and loss of appetite and low grade fever.  He was having intermittent back pain since then After 2 months, in the last week of Aug
Read more